1. A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission
precautions should the nurse initiate?
a.
... [Show More] Contact
b. Droplet
c. Airborne
d. Protective
2. A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep
thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the following responses
should the nurse make?
a. “You would have so much more time with your family.”
b. “You should consider getting a part-time job or doing volunteer work.”
c. “Let’s talk about how the change in your job status will affect you.”
d. “Why wouldn’t you want to retire and relax?”
3. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary
and alternative therapies for pain control. The nurse should inform the client that this condition is a
contraindication for which of the following therapies?
a. Biofeedback
b. Aloe
c. Feverfew
d. Acupuncture
4. A nurse is assessing an older adult client’s risk for falls. Which of the following assessments should the
nurse use to identify the client’s safety needs? SATA
a. Lacrimal apparatus
b. Pupil clarity
c. Appearance of bulbar conjunctivae
d. Visual fields
e. Visual acuity
5. A nurse is caring for a child who has a prescription for a blood transfusion. The child’s parents have refused
the treatment due to their religious beliefs. Which of the following actions should the nurse take?
a. Examine personal values about the issue
b. Tell the parents that this is a necessary procedure
c. Inform the parents that the staff does not require their consent
d. Contact a spiritual support person to explain the importance of the procedure
6. A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of
thigh-length sequential compression sleeves. Which of the following actions should the nurse take?
a. Assist the client into a prone position
b. Place a sleeve over the top of each leg with an opening at the kne
c. Make sure two fingers can fit under the sleeves
d. Set the ankle pressure at 65 mmHg
7. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a
newly licensed nurse. Which of the following actions should the nurse include?
a. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter
b. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min
c. Make sure the reservoir bag of a partial rebreathing mask remains deflated
d. Use petroleum jelly to lubricate the client’s nares, face, and lips
8. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the
following actions should the nurse take?
a. Discuss the risk factors for colon cancer
b. Focus teaching on what the client will need to do in the future to manage his illness
c. Provide the client with written information about the phases of loss and grief
d. Reassure the client that this is an expected response to grief
9. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following
actions should the nurse take first?
a. Check the client for injuries
b. Move hazardous objects away from the client
c. Notify the provider
d. Ask the client to describe how she felt prior to the fall
10. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following
major abdominal surgery. Which of the following actions is the nurse’s priority?
a. Request that a respiratory therapist discuss the technique for incentive spirometry with the
client.
b. Determine the reasons why the client is refusing to use the incentive spirometer
c. Document the client’s refusal to participate in health restorative activities
d. Administer a pain medication to the client
e.
11. A nurse is admitting a client to a healthcare facility. The nurse is placing the client on isolation precautions.
Which of the following interventions should the nurse include?
a. Wear an N95 mask when caring for the client
b. Place a container for soiled linens inside the client’s room
c. Place the client in a negative airflow room
d. Remove mask after exiting the client’s room
e. Wear a sterile, water-resistant gown if within 3 feet of the client.
12. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following
statements should the nurse identify as an indication that the client understands the preoperative
teaching she received about pain management?
a. “I think I should take my pain medication more often, since it is not controlling my pain.”
b. “Breathing faster will help me keep my mind off of the pain.”
c. “It might help me to listen to music while I’m lying in bed.”
d. “I don’t want to walk today because I have some pain.”
13. A nurse in a long-term care facility is carig for a client who dies on the nurse’s shift. Identify the sequence
in which a nurse should perform the following steps:
a. (1) obtain the pronouncement of death from the provider
b. (2) remove tubes and indwelling lines
c. (3) wash the client's body
d. (4) ask the client's family if they would like to view the body
e. (5) place a name tag on the body
14. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following
findings should the nurse report to the provider?
Nurses' Notes
1100:
Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is
oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal
dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow
urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails
raised x 2, call light in the client's reach.
1115:
Provider prescriptions reviewed.
1200:
Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact,
no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and
metoclopramide 10 mg IV bolus administered.
1230:
Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional
urine output since 1200. Repositioned client for comfort.
Medication Administration Record
Morphine 4 mg IV bolus every 4 hr PRN pain
Metoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting
Vital Signs
1100:
Temperature 36.2° C (97.2° F)
Heart rate 76/min
Respirations 18/min
BP 122/68 mm Hg
Oxygen saturation 95% on room air
1200:
Temperature 36.8° C (98.2° F)
Heart rate 116/min
Respirations 20/min [Show Less]